Welcome to PICU Doc On Call, A Podcast Dedicated to Current and Aspiring Intensivists.
I'm Pradip Kamat and I'm Rahul Damania and we are coming to you from Children's Healthcare of Atlanta - Emory University School of Medicine in Atlanta, GA.Today we are going to present a case of a 3 year old presenting with bilateral hyper-flexed wrists.
Here is Rahul with our case:
A 3 yo previously healthy M presents to the emergency department after his mother noted his wrists becoming completely stiff and flexed. Despite several attempts to stretch out his wrist, his mother was unable to place them back into position. She brought him to the ED for further evaluation. Importantly, mother denies any trauma or injury. Mom notes that this happened once before one month ago. The episode lasted 10 min and self-resolved. She did not seek medical attention at that time. Patient has no history of bleeding, bruising or chronic medical conditions. His immunizations are UTD. Family hx was relatively unremarkable however the mother states that she gets admitted to the hospital for Kidney Stones 4-5 times per year. She usually follows with a urologist. Though she is on diuretic therapy for recurrent renal stones, she denies that her son has any access to these medications & also denies any ingestion. She does state that patient is a picky eater and does not drink milk but will eat cheese often with 4-5 cups of juice. Mother denies any recent upper respiratory tract symptoms, vomiting, constipation, urinary abnormalities or changes in gait.
Upon presentation to the ED, his vital signs were stable. His physical exam is normal except for Bilateral hands in flexion with digits on flexion as well. After some resistance the examiner was able to extend hands. There were no abrasions or signs of cutaneous injury in his bilateral hands. Full range of motion of elbow and shoulder as well as full range of motion of ankle and knee as well as hip. Prior to drawing blood for a diagnostic work-up the patient undergoes an EKG which shows some artifact but is notable for a prolonged QTc interval of 560.
To summarize key elements from this case so far, we have a toddler with
Bilateral hyper-flexion of the wrists which seem to be in a tonic state and is recurrent
A family history of renal metabolic disease.
and finally, an EKG abnormality.
Rahul one key pertinent negative at this stage is that there is no trauma & patient has full range of motion at other large joints
Rahul, let's transition to key history and physical elements when you think about bilateral wrist flexion.

This is an interesting chief complaint, however I would tailor my history to assess for trauma as this seems to be a primary MSK issue.

The key feature here is that the patient has bilateral wrist involvement which brings up the concern for an underlying systemic cause such as an electrolyte abnormality, connective tissue disorder, or muscular abnormality. The family history of recurrent kidney stones points more towards a familial renal or electrolyte problem.
I would ask about any trauma related to skin wounds. As this patient is in a tonic state, I would worry about tetanus.
I would also get a good dietary history as excessive juice consumption may have limited nutritional value.

On physical exam, I would look for any other MSK abnormalities with this bilateral wrist flexion. Especially if we are heading down the route of nutritional abnormality, electrolyte disturbance or renal anomaly, I would like to assess for any bowing of the legs, joint flaring, any metacarpal shortening, or rib abnormality.

Pradip, I would love to hear more about the emergency room diagnostic work-up in this patient...
To continue with our case, the patients labs were consistent with:
A very low ionized calcium of 2.2 (normal 4.4-5.4mg/dl). Also, his total serum Ca was low — < 5mg/dL (Nl range 8.9-10.4mg/dl) with a relatively normal albumin.
His CMP was notable for an elevated...